CSU IMM BAND STUDENT HEALTH RECORD
PART 1 - TO BE FILLED OUT BY THE STUDENT

Name

DOB

Email

Sex

Female
Male

Phone #

Cellular #

Present Address

Permanent Address

Medical History

1

Are there any restrictions to physical activity, please explain

2

Have you been treated by a physician or nurse practitioner in the past 5 yrs? For what reason ?

3

Have you ever been hospitalized ? If so, why?

4

Do you have Medical Insurance ? Company and policy #

5

Are you allergic to any medications or latex?

6

Give month and year of last vaccinations/inoculations
MMR:
Tetanus or Td:
PPD:
Results:
Neg.
Pos.

Check all the following which apply to you and close relatives (parents, siblings, 1st grandparents)
Please indicate who:

You

Relative
(ex: parents, siblings, grandparents)

You

Relative
(ex: parents, siblings, grandparents)

Allergies

Headaches

Anemia

Hepatitis

Asthma

Hypertension

Cancer

High Cholesterol

Cardiovascular

Stomach/Bowel

Diabetes

Kidney Disease

Drug & Alcohol

Skin Disease

Mental Problems

Thyroid Disease

Gallbladder/Liver

Tuberculosis

Other, please explain

I certify to the best of my knowledge that the above information is complete and correct.

Applicant's Signature

Date

AUTHORIZATION FOR MEDICAL, DENTAL, SURGICAL, OR OTHER TREATMENT
I hereby authorize and consent to deemed necessary or advisable services, including but not limited
to diagnostic procedures, radiology, laboratory, anesthesia, medical, surgical, dental, and or hospital
services.

Signature

Date

PART 2 - TO BE COMPLETED BY A PHYSICIAN OR NURSE PRACTITIONER

Weight

Height

BP

Pulse

Vision

Test ---- Urinalysis: Albumin

Glucose

Serum: Hemoglobin

HCT

Is the applicant currently receiving treatment?
If so, why?

CLINICAL EVALUATION

Check each item in the appropriate column

Normal

Abnormal

If Abnormal, Describe

1. Skull, Scalp, Face, Neck, Thyroid

2. Skin, Lymphatic

3. Ears, Nose, Throat

4. Eyes

5. Neurological

6. Lungs and Chest

7. Heart

8. Abdomen

9. Perineum, rectum, hernias

10. Endocrine

11. Musculoskeletal

12. Psychiatric

Please indicate any medical condition which would interfere with regular physical activity.